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General NPI Number Information
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NPI Number | 1659610608
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Entity Type | Organization
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Legal Business Name | GREAT LAKES TTC,LLC
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Dates
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Enumeration Date | 02/12/2013
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Last Update Date | 02/12/2013
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Provider Practice Location Address
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Address Line | 2206 MITCHELL PARK DR STE 10
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City | PETOSKEY
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State | MI
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Zip | 49770-8674
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Country | US
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Telephone | 231-487-2415
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Fax |
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Provider Business Mailing Address
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Address Line | 6935 ZENITH HEIGHTS RD
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City | BOYNE CITY
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State | MI
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Zip | 49712-9356
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Country | US
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Telephone | 231-675-5032
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEREK EVERETT JOHNSON
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Credential | LMSW
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Telephone | 231-487-2415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 6801089396
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License Number State | MI
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